Bocage Animal Hospital
7353 Jefferson Highway
Baton Rouge LA 70806
225-928-7550
Surgery Waiver
Owner: __________________________________
Address: _____________________________________________________________
City, State, Zip: _______________________________________________________
Pet’s Name: _________________ Species: __________ Breed: __________ Color: __________
Age: ______ Sex: __________
_____________ will be undergoing surgery for __________________ on ______________(date).
I have also been informed that there are certain risks and complications, including death, associated with
any operation or procedure of this type. I further understand that during the course of the operations or
procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures.
Please initial in the spaces provided below to authorize or decline medical procedures.
Blood Work
Basic anesthesia charges include an initial physical exam, pre-anesthetic assessment of anemia or kidney
disease, and monitoring of cardiac function during anesthesia. I understand that underlying disease may
increase anesthetic risk, especially in animals over 5 years of age or in ill animals. The doctor’s choice of
anesthetic medications may be altered accordingly if pre-existing problems are known. Pre-anesthetic
blood work will be run in order to determine if surgery will be performed to help to alert the doctor to these
conditions. As the responsible owner/party I understand these conditions. ___________
Micro Chip
We offer identification microchips for <_________>. This chip can be injected while your pet is under
anesthesia. The benefit of having your pet chipped is permanent identification for the life of your pet. Your
pet will have a one-of-a-kind number that is specific to only to them.
I _______ authorize / _______decline to have <__________> micro chipped while under anesthesia at a
cost of $49.00.
“Living Will” Clause
In the event of life-threatening complications, I ______authorize / _______ decline the use of measures to
revive <___________>.
Dental Extractions
If <___________> is having any dental procedures today there is always a possibility they will need
extractions. The doctor will examine all teeth while <___________> is under anesthesia and determine
which, if any, teeth will require extraction. Simple or complex extractions may be necessary at an
additional cost. I ______authorize / ______ decline extractions. Does not apply to <___________>
Pain Control Clause
I understand that surgical procedures result in pain. The doctors and staff of Bocage Animal Hospital
strongly recommend post-operative pain medications. I understand that no medication will completely
relieve pain. The doctor will prescribe the medication he/she feels is best for <__________>.
I _______ authorize / _______ decline pain medication to be prescribed for <__________>.
I am the owner or the agent for the owner for the animal described above, and I have the authority to
execute this consent.
Signed: _______________________________________ Date: __________________